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Erschienen in: Annals of Surgical Oncology 2/2019

11.10.2018 | Melanoma

Management of Sentinel Lymph Node Metastasis in Merkel Cell Carcinoma: Completion Lymphadenectomy, Radiation, or Both?

verfasst von: Matthew C. Perez, MD, Daniel E. Oliver, MD, Evan S. Weitman, MD, David Boulware, PhD, Jane L. Messina, MD, Javier Torres-Roca, MD, C. Wayne Cruse, MD, Ricardo J. Gonzalez, MD, Amod A. Sarnaik, MD, Vernon K. Sondak, MD, Evan J. Wuthrick, MD, Louis B. Harrison, MD, Jonathan S. Zager, MD

Erschienen in: Annals of Surgical Oncology | Ausgabe 2/2019

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Abstract

Background

Approximately 30% of patients with clinically localized Merkel cell carcinoma (MCC) show nodal involvement on sentinel lymph node biopsy (SLNB). Optimal management of SLNB-positive disease has not been defined. This study compared outcomes after completion lymphadenectomy (CLND), radiation, and combined CLND plus radiation after a positive SLNB.

Methods

All patients treated at a single institution for SLNB-positive MCC (1998–2015) were retrospectively evaluated, with examination of patient demographics, clinicopathologic characteristics, outcomes, and regional toxicity.

Results

The study identified 71 evaluable patients with SLNB-positive disease. The median age of these patients was 76 years, and 76.1% were men. Of the 71 patients, 11 (15.5%) underwent CLND, 40 (56.3%) received radiation, and 20 (28.2%) underwent CLND plus postoperative radiation. Lymphovascular invasion was significantly more common in the radiation-alone cohort (p = 0.04). For the three cohorts, the median percentages of nodal involvement were respectively 2, 10, and 30% (p = 0.06). After a median follow-up period of 22.3 months, four patients had recurrence in their regional nodal basin (3 radiation-alone patients and 1 CLND + radiation patient). The three cohorts did not differ significantly in the development of distant metastases (p = 0.68) or overall survival (p = 0.72). Six patients experienced surgical-site infections (2 CLND and 4 CLND + radiation patients), and three patients experienced symptomatic lymphedema (1 CLND patient and 2 CLND + radiation patients).

Conclusions

Regional failure was infrequent (≤ 10%) regardless of treatment, and morbidity appeared to be low with all approaches. Given that multiple treatment approaches can be successful in treating micrometastatic MCC, future efforts should be directed at refining criteria for allocating patients to a specific method, or possibly no further nodal basin treatment, in an effort to maximize regional control at the lowest cost and morbidity.
Literatur
2.
Zurück zum Zitat Rollison DE, Giuliano AR, Becker JC. New virus associated with merkel cell carcinoma development. JNCCN J Natl Compr Cancer Netw. 2010;8(8):874–880.CrossRef Rollison DE, Giuliano AR, Becker JC. New virus associated with merkel cell carcinoma development. JNCCN J Natl Compr Cancer Netw. 2010;8(8):874–880.CrossRef
3.
Zurück zum Zitat Wong SQ, Waldeck K, Vergara IA, et al. UV-associated mutations underlie the etiology of MCV-negative Merkel cell carcinomas. Cancer Res. 2015;75:5228–34.CrossRefPubMed Wong SQ, Waldeck K, Vergara IA, et al. UV-associated mutations underlie the etiology of MCV-negative Merkel cell carcinomas. Cancer Res. 2015;75:5228–34.CrossRefPubMed
4.
Zurück zum Zitat Goes HFO, Lima CDS, Issa MCA, Luz FB, Pantaleao L, Paixao J. Merkel cell carcinoma in an immunosuppressed patient. Anais Brasileiros Dermatol. 2017;92:386–8.CrossRef Goes HFO, Lima CDS, Issa MCA, Luz FB, Pantaleao L, Paixao J. Merkel cell carcinoma in an immunosuppressed patient. Anais Brasileiros Dermatol. 2017;92:386–8.CrossRef
5.
Zurück zum Zitat Paulson KG, Park SY, Vandeven NA, et al. Merkel cell carcinoma: current United States incidence and projected increases based on changing demographics. J Am Acad Dermatol. 2018;78:457–63.CrossRefPubMed Paulson KG, Park SY, Vandeven NA, et al. Merkel cell carcinoma: current United States incidence and projected increases based on changing demographics. J Am Acad Dermatol. 2018;78:457–63.CrossRefPubMed
6.
Zurück zum Zitat Lyhne D, Lock-Andersen J, Dahlstrom K, et al. Rising incidence of Merkel cell carcinoma. J Plast Surg Hand Surg. 2011;45:274–80.CrossRefPubMed Lyhne D, Lock-Andersen J, Dahlstrom K, et al. Rising incidence of Merkel cell carcinoma. J Plast Surg Hand Surg. 2011;45:274–80.CrossRefPubMed
7.
Zurück zum Zitat Bichakjian CK, Olencki T, Aasi SZ, et al. Merkel cell carcinoma, version 1.2018, NCCN clinical practice guidelines in oncology. JNCCN J Natl Comprehensive Cancer Network. 2018;16:742–74.CrossRef Bichakjian CK, Olencki T, Aasi SZ, et al. Merkel cell carcinoma, version 1.2018, NCCN clinical practice guidelines in oncology. JNCCN J Natl Comprehensive Cancer Network. 2018;16:742–74.CrossRef
8.
Zurück zum Zitat Kang SH, Haydu LE, Goh RY, Fogarty GB. Radiotherapy is associated with significant improvement in local and regional control in Merkel cell carcinoma. Radiat Oncol Lond Engl. 2012;7:171.CrossRef Kang SH, Haydu LE, Goh RY, Fogarty GB. Radiotherapy is associated with significant improvement in local and regional control in Merkel cell carcinoma. Radiat Oncol Lond Engl. 2012;7:171.CrossRef
9.
Zurück zum Zitat Strom T, Carr M, Zager JS, et al. Radiation therapy is associated with improved outcomes in Merkel cell carcinoma. Ann Surg Oncol. 2016;23:3572–8.CrossRefPubMed Strom T, Carr M, Zager JS, et al. Radiation therapy is associated with improved outcomes in Merkel cell carcinoma. Ann Surg Oncol. 2016;23:3572–8.CrossRefPubMed
10.
Zurück zum Zitat Allen PJ, Bowne WB, Jaques DP, Brennan MF, Busam K, Coit DG. Merkel cell carcinoma: prognosis and treatment of patients from a single institution. J Clin Oncol. 2005;23:2300–9.CrossRefPubMed Allen PJ, Bowne WB, Jaques DP, Brennan MF, Busam K, Coit DG. Merkel cell carcinoma: prognosis and treatment of patients from a single institution. J Clin Oncol. 2005;23:2300–9.CrossRefPubMed
11.
Zurück zum Zitat Gupta SG, Wang LC, Penas PF, Gellenthin M, Lee SJ, Nghiem P. Sentinel lymph node biopsy for evaluation and treatment of patients with Merkel cell carcinoma: the Dana-Farber experience and meta-analysis of the literature. Arch Dermatol. 2006;142:685–90.CrossRefPubMed Gupta SG, Wang LC, Penas PF, Gellenthin M, Lee SJ, Nghiem P. Sentinel lymph node biopsy for evaluation and treatment of patients with Merkel cell carcinoma: the Dana-Farber experience and meta-analysis of the literature. Arch Dermatol. 2006;142:685–90.CrossRefPubMed
12.
Zurück zum Zitat Fang LC, Lemos B, Douglas J, Iyer J, Nghiem P. Radiation monotherapy as regional treatment for lymph node-positive Merkel cell carcinoma. Cancer. 2010;116:1783–90.CrossRefPubMed Fang LC, Lemos B, Douglas J, Iyer J, Nghiem P. Radiation monotherapy as regional treatment for lymph node-positive Merkel cell carcinoma. Cancer. 2010;116:1783–90.CrossRefPubMed
13.
Zurück zum Zitat Sundaresan P, Hruby G, Hamilton A, et al. Definitive radiotherapy or chemoradiotherapy in the treatment of Merkel cell carcinoma. Clin Oncol R Coll Radiol G B. 2012;24:e131–136.CrossRef Sundaresan P, Hruby G, Hamilton A, et al. Definitive radiotherapy or chemoradiotherapy in the treatment of Merkel cell carcinoma. Clin Oncol R Coll Radiol G B. 2012;24:e131–136.CrossRef
14.
Zurück zum Zitat Veness M, Foote M, Gebski V, Poulsen M. The role of radiotherapy alone in patients with Merkel cell carcinoma: reporting the Australian experience of 43 patients. Int J Radiat Oncol Biol Phys. 2010;78:703–9.CrossRefPubMed Veness M, Foote M, Gebski V, Poulsen M. The role of radiotherapy alone in patients with Merkel cell carcinoma: reporting the Australian experience of 43 patients. Int J Radiat Oncol Biol Phys. 2010;78:703–9.CrossRefPubMed
15.
Zurück zum Zitat Ghadjar P, Kaanders JH, Poortmans P, et al. The essential role of radiotherapy in the treatment of Merkel cell carcinoma: a study from the Rare Cancer Network. Int J Radiat Oncol Biol Phys. 2011;81:e583–91.CrossRefPubMed Ghadjar P, Kaanders JH, Poortmans P, et al. The essential role of radiotherapy in the treatment of Merkel cell carcinoma: a study from the Rare Cancer Network. Int J Radiat Oncol Biol Phys. 2011;81:e583–91.CrossRefPubMed
16.
Zurück zum Zitat Faries MB, Thompson JF, Cochran AJ, et al. Completion dissection or observation for sentinel-node metastasis in melanoma. N Engl J Med. 2017;376:2211–22.CrossRefPubMedPubMedCentral Faries MB, Thompson JF, Cochran AJ, et al. Completion dissection or observation for sentinel-node metastasis in melanoma. N Engl J Med. 2017;376:2211–22.CrossRefPubMedPubMedCentral
17.
Zurück zum Zitat Postlewait LM, Farley CR, Seamens AM, et al. Morbidity and outcomes following axillary lymphadenectomy for melanoma: weighing the risk of surgery in the era of MSLT-II. Ann Surg Oncol. 2018;25:465–70.CrossRefPubMed Postlewait LM, Farley CR, Seamens AM, et al. Morbidity and outcomes following axillary lymphadenectomy for melanoma: weighing the risk of surgery in the era of MSLT-II. Ann Surg Oncol. 2018;25:465–70.CrossRefPubMed
18.
Zurück zum Zitat Faries MB, Thompson JF, Cochran A, et al. The impact on morbidity and length of stay of early versus delayed complete lymphadenectomy in melanoma: results of the Multicenter Selective Lymphadenectomy Trial (I). Ann Surg Oncol. 2010;17:3324–9.CrossRefPubMedPubMedCentral Faries MB, Thompson JF, Cochran A, et al. The impact on morbidity and length of stay of early versus delayed complete lymphadenectomy in melanoma: results of the Multicenter Selective Lymphadenectomy Trial (I). Ann Surg Oncol. 2010;17:3324–9.CrossRefPubMedPubMedCentral
19.
Zurück zum Zitat Sabel MS, Griffith KA, Arora A, et al. Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy. Surgery. 2007;141:728–35.CrossRefPubMed Sabel MS, Griffith KA, Arora A, et al. Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy. Surgery. 2007;141:728–35.CrossRefPubMed
20.
Zurück zum Zitat Sarnaik AA, Puleo CA, Zager JS, Sondak VK. Limiting the morbidity of inguinal lymphadenectomy for metastatic melanoma. Cancer Control. 2009;16:240–7.CrossRefPubMed Sarnaik AA, Puleo CA, Zager JS, Sondak VK. Limiting the morbidity of inguinal lymphadenectomy for metastatic melanoma. Cancer Control. 2009;16:240–7.CrossRefPubMed
21.
Zurück zum Zitat Mathew J, Barthelmes L, Neminathan S, Crawford D. Comparative study of lymphoedema with axillary node dissection versus axillary node sampling with radiotherapy in patients undergoing breast conservation surgery. Eur J Surg Oncol. 2006;32:729–32.CrossRefPubMed Mathew J, Barthelmes L, Neminathan S, Crawford D. Comparative study of lymphoedema with axillary node dissection versus axillary node sampling with radiotherapy in patients undergoing breast conservation surgery. Eur J Surg Oncol. 2006;32:729–32.CrossRefPubMed
22.
Zurück zum Zitat Chaukar DA, Walvekar RR, Das AK, et al. Quality of life in head and neck cancer survivors: a cross-sectional survey. Am J Otolaryngol. 2009;30:176–80.CrossRefPubMed Chaukar DA, Walvekar RR, Das AK, et al. Quality of life in head and neck cancer survivors: a cross-sectional survey. Am J Otolaryngol. 2009;30:176–80.CrossRefPubMed
23.
Zurück zum Zitat Edge SB, Cancer AJCo. AJCC Cancer staging handbook: from the AJCC cancer staging manual, vol 2010. New York: Springer; 2010. Edge SB, Cancer AJCo. AJCC Cancer staging handbook: from the AJCC cancer staging manual, vol 2010. New York: Springer; 2010.
Metadaten
Titel
Management of Sentinel Lymph Node Metastasis in Merkel Cell Carcinoma: Completion Lymphadenectomy, Radiation, or Both?
verfasst von
Matthew C. Perez, MD
Daniel E. Oliver, MD
Evan S. Weitman, MD
David Boulware, PhD
Jane L. Messina, MD
Javier Torres-Roca, MD
C. Wayne Cruse, MD
Ricardo J. Gonzalez, MD
Amod A. Sarnaik, MD
Vernon K. Sondak, MD
Evan J. Wuthrick, MD
Louis B. Harrison, MD
Jonathan S. Zager, MD
Publikationsdatum
11.10.2018
Verlag
Springer International Publishing
Erschienen in
Annals of Surgical Oncology / Ausgabe 2/2019
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-018-6810-1

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